Provider Demographics
NPI:1083727838
Name:RAJA TALLURI MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:RAJA TALLURI MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:THIBODAUX MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GAYATHRI
Authorized Official - Middle Name:
Authorized Official - Last Name:TALLURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-414-0682
Mailing Address - Street 1:1214 CARDINAL DR
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4815
Mailing Address - Country:US
Mailing Address - Phone:985-446-6381
Mailing Address - Fax:985-446-5992
Practice Address - Street 1:931 N CANAL BLVD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-8095
Practice Address - Country:US
Practice Address - Phone:985-446-6381
Practice Address - Fax:985-446-5992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2152858Medicaid